Bosch and Duch BMC Pediatrics (2017) 17:178

DOI 10.1186/s12887-017-0918-5

RESEARCH ARTICLE Open Access

The role of cognitive stimulation at home

in low-income preschoolers’ nutrition,
physical activity and body mass index
Saskia Op den Bosch1 and Helena Duch2,3*

Abstract
Background: Early childhood obesity disproportionately affects children of low socioeconomic status. Children
attending Head Start are reported to have an obesity rate of 17.9%.This longitudinal study aimed to understand the
relationship between cognitive stimulation at home and intake of junk food, physical activity and body size,
for a nationally representative sample of 3- and 4-year old children entering Head Start.
Methods: We used The Family and Child Experiences Survey 2006. Cognitive stimulation at home was measured for
1905 children at preschool entry using items from the Home Observation Measurement of the Environment Short
Form. Junk food consumption and physical activity were obtained from parent interviews at kindergarten entry. BMI z
scores were based on CDC national standards. We analyzed the association between early cognitive stimulation and
junk food consumption, physical activity and BMI, using multinomial and binary logistic regression on a weighted
sample.
Results: Children who received moderate levels of cognitive stimulation at home had a 1.5 increase in the likelihood
of consuming low amounts of junk food compared to children from low cognitive stimulation environments. Children
who received moderate and high levels of cognitive stimulation were two and three times, respectively, more likely to
be physically active than those in low cognitive stimulation homes. No direct relationship was identified between
cognitive stimulation and BMI.
Conclusion: Prevention and treatment efforts to address early childhood obesity may consider strategies that support
parents in providing cognitively stimulating home environments. Existing evidence-based programs can guide
intervention in pediatric primary care.

Background established that obesity is a result of complex interac-

Childhood obesity has more than tripled in the last
30 years, with a prevalence of 8.4% among children ages
2 to 5 [1]. In addition, obesity disproportionately affects
children of low socioeconomic status, with a rate of
nearly 15% for children under the age of 5 [1] in this
group. Children who are obese have a greater chance of
being obese during adulthood, increasing the likelihood
of serious health conditions such as heart disease, stroke,
type 2 diabetes and various forms of cancer [2]. It is well
* Correspondence: hd90@cumc.columbia.edu
2
Mailman School of Public Health, Columbia University, New York, NY, USA
3
Mailman School of Public Health, Department of Population and Family
Health, Columbia University, 60 Haven Avenue, B-2, New York, NY 10032,
USA
Full list of author information is available at the end of the article
tions between genetic, environmental, and social factors
[3, 4]. One current model proposes six levels of contrib-
utors: cellular, child, clan, community, country and cul-
ture [5]. For young children, the clan or family level may
be of particular importance as young children spend
most of their time at home [6].
Within the clan/family level, one intriguing factor—par-
ental stimulation of the child’s cognitive development (e.g.
opportunities for play and learning)—has been linked to
the prevention of overweight and obesity. Strauss &
Knight [7], using a nationally representative sample of
U.S. children, identified a greater than two-fold increase in
the risk of developing obesity for children exposed to low
levels of cognitive stimulation in their early home environ-
ment. Additionally, work of Garasky and colleagues, [8]

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Bosch and Duch BMC Pediatrics (2017) 17:178 Page 2 of 7

investigating a variety of family stressors and their influ- was 1905 children and their families (see Table 1 for
ence on body mass index (BMI) outcomes in children, demographics) and includes almost equal numbers of en-
supported a positive association between lack of cognitive rolling 3- (51%) and 4-year olds (49%). Most of the sample
stimulation and child overweight and obesity. While these was Hispanic (37%), with comparable numbers of Whites
studies point to cognitive stimulation in the early home (24%) and African-Americans (30%). Thirty nine percent
environment as an important influence on the develop- of mothers had less than a high school diploma. Seventy-
ment of obesity, the mechanisms by which the home two percent of participants reported a household income
environment may be associated to body size in childhood below 30,000 dollars per year. A majority of the sampled
are still largely unknown. children (85%) had normal birth weight. Analysis of de-
In the preschool years, parents have significant control identified data was used for this study and it was exempt
over their children’s nutrition [9–13] and opportunities from Columbia University’s Institutional Review Board. A
for physical activity, [14–17] both of which significantly restricted license for FACES 2006 was obtained for work
influence obesity. Therefore, this study examines the on this manuscript.
association between cognitive stimulation at home, nutri-
tion, physical activity and Body Mass Index (BMI z score). Predictor variable
While previous work has documented a relationship Cognitive stimulation
between cognitive stimulation in the home and body mass To develop a cognitive stimulation composite variable from
index, our work extends this prior literature but examin- the questions used in the FACES 2006 parent interview, we
ing the relationship between cognitive stimulation and matched the FACES 2006 items [19] to questions used in
more proximal outcomes, like junk food consumption and the Home Observation Measurement of the Environment-
physical activity. Short Form (HOME-SF), a nationally-recognized, stan-
Given that obesity in early childhood is almost double dardized measure for assessing the home environment of
among low income children, [1] our study focuses on young children [7]. After matching, a total of 22 items were
participants in the federally funded Head Start program,
which reports an obesity rate of 17.9% and an over- Table 1 Demographic characteristics of sampled children and
weight rate of 19.9% among participating children, [18] their familiesab
making this a crucial population to study in understand- Demographics Total number Percent of sample
ing contributors to early childhood obesity in America. (of Sampled children)
We hypothesize, first, that independent of socio- Gender
demographic factors, moderate to high levels of cognitive Male 991 52.0%
stimulation in the home at preschool entry will be associ- Female 914 48.0%
ated with higher levels of physical activity and lower levels Race/ Ethnicity
of junk food consumption at the end of kindergarten. Sec- White 457 24.0%
ond, based on the results of Strauss and Knight [7], we Black 572 30.0%
Hispanic 705 37.0%
hypothesize that lower levels of cognitive stimulation in Other 171 9%
the home at preschool entry will be associated with higher
Maternal Education
body mass index (BMI) at the end of kindergarten. The
findings from this study can be used to inform the devel- Less than High School 743 39.0%
High School or GEDc 591 31.0%
opment of interventions that consider the impact of home More than High School 572 30.0%
influences on young children’s nutrition and physical Household Income
activity practices, and ultimately on body size.
Less than 30 K 1372 72.0%
Greater than 30 K 533 28.0%
Methods
Marital Status
Participants
Not Married 1238 65.0%
The Family and Child Experiences Survey dataset (FACES, Married 667 35.0%
2006) was used for this study [19]. There are five FACES
Birth Weightd
cohorts (1997, 2000, 2003, 2006 and 2009), each including
a nationally representative sample of 3- to 4- year-old Normal Weight (>5.5lbs) 1619 85.0%
children entering Head Start for the first time. Data are Cohort
collected on children and families at three time points in % 3-year olds 51.0%
the span of 2 years: 1) fall of child’s first year in Head Start, % 4-year olds 49.0%
a
2) spring of the same year, and 3) spring of the following b
N = 1905 weighted sample
Updated at Follow-up, 2009
year. This study focuses on the baseline (2006) and the last c
General Education Diploma
two waves of data collection (2008 and 2009). Sample size d
Excludes cases of birthweight >5.5 lbs
Bosch and Duch BMC Pediatrics (2017) 17:178 Page 3 of 7

selected and re-coded to match the coding for the percentile, where low consumption meant that a child
HOME-SF and summed to create a composite vari- did not have junk food more than 3 times in 1 week,
able (see Table 2). As per the HOME-SF scoring and and moderate consumption meant the child did not
following the work of Strauss & Knight, [7] cutoff have junk food more than once a day. Information on
points were created at the 15th and 85th percentiles consumption of healthy foods was not available in this
and categorized as: 0–11 = 1 (low cognitive stimula- dataset.
tion), 12–17 = 2 (medium cognitive stimulation), and
18–23 = 3 (high cognitive stimulation). Physical activity
To create a dichotomous variable of physical activity
Outcome variables level, information on whether a parent took the child to
Junk food consumption participate in a game/sport/exercise in the past week
Food consumption was evaluated using parental reports (1 = yes, 0 = no) and whether parent took child to a
of consumption of junk food per week, obtained during playground/park (1 = yes, 0 = no) was added and coded
the third and fourth follow-up interviews (in 2008 and as 1 = active and 0 = not active, where active meant that
2009, respectively). Four categories of junk food were parent had engaged the child in both activities in the
defined in creating a junk food score: sugary snacks; past week.
cookies, cakes and brownies; fast food; and salty snacks.
Answers were scored on a scale of 0 to 5 depending on BMI Z scores and categories
frequency of consumption. The score on the 0–5 rating We based our BMI z scores and categories on the
scale was then re-coded into categories (no consump- Center for Disease Control (CDC) national standards for
tion, low consumption, moderate consumption, high children ages 2 to 5, based on height, weight, gender and
consumption) based on cut-offs at the 15th and 85th age in months [20]. BMI z scores were generated using
the STATA commands zanthro() and zbmicat() which
Table 2 Coding key for cognitive stimulation composite take as their primary argument a child’s BMI composite,
questionsa available in the FACES 2006 dataset [19]. Scores for BMI
Question Coding are categorized into 1 = normal weight, 2 = overweight
Frequency read to child in past week 0 = less than 3× / and 3 = obese, where z scores above the 85th percentile
1 = 3× or more are categorized as overweight and above the 95th
No. of minutes/day child is read to 0 = less than 20 min / percentile as obese, using a BMI-for-age reference chart
0 = more than 20 min in the US [20].
Told them a story 0 = no / 1 = yes
Taught child letters, words, numbers 0 = no / 1 = yes Analysis
All analyses were weighted using the FACES 2006
Taught child songs or music 0 = no / 1 = yes
weight, PRA16WT, and conducted in STATA 10 using
Worked on arts and crafts with child 0 = no / 1 = yes
the statistical package svyset() and the Taylor-Series
Took child on errands 0 = no / 1 = yes method to adjust variances. To test bivariate relation-
Involved child in household chores 0 = no / 1 = yes ships between study variables, cross tabulations and chi-
Talked about what happened in Head Start 0 = no / 1 = yes square tests of independence were performed on the
Talked about TV programs/videos 0 = no / 1 = yes weighted sample (n = 1905).
The association between early cognitive stimulation
Played counting games 0 = no / 1 = yes
and consumption of junk food (dependent variable) at
Visited a library with child 0 = no / 1 = yes
follow up was analyzed using multinomial logistic
Gone to a movie with child 0 = no / 1 = yes regression, converting log odds to relative risk ratios for
Gone to a play or concert with child 0 = no / 1 = yes each level of the dependent variable, and controlling for
Gone to a mall with child 0 = no / 1 = yes socio-demographic variables.
Visited art gallery or museum 0 = no / 1 = yes The association between early cognitive stimulation
and physical activity levels at follow up (dependent vari-
Visited zoo or aquarium with child 0 = no / 1 = yes
able) was estimated using binary logistic regression ana-
Talked with child about heritage 0 = no / 1 = yes
lyses, adjusting for socio-demographic factors (maternal
Attend community sponsored event 0 = no / 1 = yes education, child birth weight, race, age, and gender).
Attended church activity/school 0 = no / 1 = yes Because the majority of the sample (Table 1) was in
Number of children books in household 0 = less than 10 / the same category of household income (72% below
1 = more than 10 $30,000) and marital status (65% not married), these var-
a
Composite variable created as a sum of these items iables were dropped from the analyses, as they did not
Bosch and Duch BMC Pediatrics (2017) 17:178 Page 4 of 7

improve the explanatory power and significance of the Table 4 Relative risk of low junk food consumption predicted
overall model. by cognitive stimulation in 2008 [F(39,9) = 319.7, p = 0.000]
Relative risk ratio and 95% CI
Results of low junk food consumption
Table 3 summarizes the distribution for the outcome Medium Cognitive Stimulationa 1.5* (1.02, 2.29)
b
and predictor variables of interest. The majority of chil- Maternal Education > High School 1.5** (1.08, 2.20)
dren (65%) had medium levels of cognitive stimulation Additional covariates in model:
at home while approximately 18% had low or high levels. Birth weight 0.96 (0.88, 1.07)
The majority of children were not active (71%) and con- c
Race:
sumed moderate amounts of junk food (58%). The per-
centage of overweight children was between 16 and 21% African American 0.70 (0.47, 1.03)
throughout the study years, while the percentage of Hispanic/Latino 1.0 (0.73, 1.37)
obese children ranged between 6 and 14%. American Indian/ Alaska native 0.60 (0.21, 1.64)
Our hypothesis that lower levels of cognitive stimula- Asian or Pacific Islander 2.57 (0.51, 13)
tion in the home at preschool entry is associated with Multiracial 1.3 (0.63, 2.77)
BMI z score at the end of kindergarten was not sup-
Other race 0.70 (0.21, 2.39)
ported by the data: cross tabulation between cognitive
stimulation and BMI categories did not yield a signifi- Age 0.99 (0.97, 1.02)
cant statistic after a chi-squared test of independence of Gender 0.80 (0.61, 1.03)
*
variable distribution (p > 0.05). Multiple logistic regres- p < 0.05, **p < 0.02
a
compared to low cognitive stimulation
sion confirmed this lack of significance with effect sizes b
compared to less than high school
for cognitive stimulation that were not significant c
compared to White/Non Hispanic
[F(12,36) = 12.33, −.007, p = 0.462] before and after con-
trolling for demographic factors.
Our hypotheses that moderate to high levels of cogni- food consumption, a multinomial logistic regression,
tive stimulation at preschool entry are associated with adjusted for socio-demographic factors, showed that
lower levels of junk food consumption and with higher children who received moderate cognitive stimulation at
levels of physical activity at the end of kindergarten were baseline (fall 2006) had a 1.5 increase (p < 0.05) in the
partially supported by the data (Table 4). Specifically, for likelihood of consuming low amounts of junk food in
the relationship between cognitive stimulation and junk the spring of 2008, compared to children residing in
environments with low cognitive stimulation. Results in-
Table 3 Descriptives for predictor and outcome variables of dicated that high levels of cognitive stimulation at home
interestab were not associated with consuming low amounts of
Descriptive Fall 2006 Spring 2008 Spring 2009 junk food (t = 1.28, p = 0.207).
Cognitive Stimulation Analysis could not be performed for the 2009 follow up
% Low Cognitive 17 because data for the nutrition composite variable was not
available at that time point. In addition, maternal educa-
% Medium Cognitive 65
tion above high school level associated inversely with junk
% High Cognitive 18
food consumption at the 2008 follow up (p < 0.01).
Physical Activity Regarding the relationship between cognitive stimula-
% Active 29 28 tion and physical activity, binary logistic regression
% Not Activ 71 72 revealed that children who were categorized as having
Junk Food Consumption moderate cognitive stimulation at baseline were twice
(p < 0.0001) as likely to be physically active at the 2008
% Low Consumption 38 39
follow-up as those with low cognitive stimulation at
% Moderate Consumption 58 56
home (Table 5). When children had high cognitive
% High Consumption 3 4 stimulation at baseline, the odds of being active increased
BMI Category further, i.e. to three times (p < 0.0001) that of those with
% Normal Weight 76 70 71 low cognitive stimulation. This effect for children with
% Overweight 18 16 21 high cognitive stimulation at baseline remained in the
2009 follow up, when the chance of being physically
% Obese 6 14 8
a
active was two and a half times (p < 0.005) that of
N = 1905 weighted sample
b
0.01% and 0.02% of sample reported no consumption of junk food in 2008
children with low cognitive stimulation at baseline.
and 2009, respectively Together these data indicate that higher levels of cognitive
Bosch and Duch BMC Pediatrics (2017) 17:178 Page 5 of 7

Table 5 Odds of being physically active predicted by cognitive sample (low-income children) and some items in the
stimulation HOME-SF may account for these differences.
2008 2009 The results of our study inform the design of early
Odds ratio of Odds ratio of childhood obesity prevention and intervention efforts by
being active being active
OR [95%CI] OR [95%CI] highlighting an important target area, cognitive stimula-
(F = 5.11)**** (F = 2.74)** tion at home, and its possible implications for improved
Medium Cognitive Stimulationa 2.0**** (1.46,2.81) 1.42 (0.89, 2.26) physical activity and nutrition outcomes.
a
High Cognitive Stimulation 2.8**** (1.87,4.27) 2.67** (1.36,5.25)
Physical activity and cognitive stimulation
Additional covariates in model:
We identified a positive relationship between cognitive
Maternal education
stimulation and physical activity.
High School/ GED 1.04 (0.77, 1.40) 1.33 (0.83, 2.12) We measured cognitive stimulation with items from
More than High School 0.74 (0.53, 1.03) 0.94 (0.54, 1.65) the well-established and widely used HOME-SF scale
Race [21]. While some of the items in the HOME scale do
African American 1.62** (1.13, 2.32) 1.47 (0.73, 2.95) relate directly to promoting physical activity in children
** (e.g. visiting zoos, running errands), the vast majority of
Hispanic/Latino 2.00 (1.25,3.32) 1.61 (0.84, 3.09)
items do not support this construct and involve what
American Indian/ Alaska 0.43*** (0.25, 0.74) 0.31 (0.93, 1.02)
native
typically are sedentary behaviors (e.g. reading books,
teaching letters and numbers). Therefore, the relation-
Asian or Pacific Islanderb 3.89* (1.08, 14.0)
ship between parental responses to the HOME scale and
Multiracial 2.70* (1.17, 6.38) 2.05 (0.48, 8.76) increased physical activity requires further exploration.
Other race 1.30 (0.31, 5.52) 1.75 (0.24, 12.83) Studies that have examined the influence of the home
Age 1.00 (0.98, 1.02) 1.06 (0.99, 1.12) environment on preschoolers’ physical activity have identi-
Gender 1.09 (.087, 1.36) 1.24 (0.87, 1.76) fied the availability of toys that promote activity (as well as
*
p < 0.05, **p < 0.01, ***p < 0.001, ****p < 0.0001 backyard equipment), parents’ own physical activity, par-
a
compared to low cognitive stimulation ental monitoring of television use, the presence of other
b
Data for Asian Pacific Islander was omitted in 2009
children and, verbal prompts to be physically active as
positive influences on physical activity [14–17]. A next
stimulation are positively associated with physical activity, step to understanding the relationship between cognitive
and that the effect may persist over at least the short term. stimulation and physical activity promoting behaviors
In the 2008 follow up, race ethnicity was positively would be to systematically study home influences and
associated with physical activity for African American, resources for physical activity and to characterize these
Hispanic, Asian and Multi Racial children (compared to factors in assessment measures of the home environment.
Whites/non Hispanic) and negatively associated to phys-
ical activity for American Indian/Alaska Native children. Junk food consumption and cognitive stimulation
These relationships were not observed in the 2009 Our study identified an inverse relationship between
follow up. moderate levels of cognitive stimulation and junk food
consumption. The relationship between these constructs
Discussion is likely mediated by parental behaviors that are associ-
This study explored the relationship between the home ated with children’s eating habits [9, 11–13]. In support
cognitive environment, nutrition, physical activity and of this, prior research has identified maternal food
body size in a national sample of preschool aged children intake, parenting practices and attitudes to be associated
attending Head Start. Analysis of the cognitive stimulation with young children’s diet [9, 11–13]. Next steps to
composite variable showed that moderate levels of understanding the relationship between cognitive stimu-
cognitive stimulation at home at preschool entry were lation at home and junk food consumption should
associated with lower levels of junk food consump- explore how the suggested mediating effect of parental
tion. In addition, moderate and high levels of cogni- factors operates.
tive stimulation at home were associated with higher Consistent with prior research, we found an associ-
levels physical activity in kindergarten. We also tested ation between maternal education and child feeding
for an association of cognitive stimulation with BMI, behavior. Parents with less than a high school education
but unlike previous studies, [7, 8] we did not find a were more likely to have children who consumed higher
direct association between cognitive stimulation, as levels of junk food. Hendricks and colleagues [10] found
measured by items in the HOME scale short-form, that having a college degree was associated with breast-
[7] and young children’s BMI. Differences in our feeding and positive child feeding behavior, advocating
Bosch and Duch BMC Pediatrics (2017) 17:178
for targeted interventions for parents with lower levels
of education.
Opportunities for intervention
Many current efforts to reduce obesity in early childhood
have focused on improving children’s diets, encouraging
physical activity and improving community practices that
support healthy lifestyles (access to food, parks, safety…).
Our results suggest another potential type of interventio-
n—improving cognitive stimulation in the home by pro-
viding resources and activities that parents can engage in
with their children to support their overall development.
Indeed, a significant number of evidence-based pro-
grams nationally and internationally are focusing on
improving parent–child interactions and supporting early
childhood development. Some of these interventions are
delivered through home visiting such as the Nurse Family
Partnership [22] or Early Head Start, [23] and others
through center-based interventions or public health and
media campaigns such as “Too Small to Fail [24]”.
In addition, pediatricians and the primary care practice
have been home to the promotion of positive cognitive
stimulation in the home. Successful and promising pro-
grams like “Reach out and Read,” [25] “Healthy Steps,”
[26] and the “Video Interaction Project (VIP)” [27]
amongst others, have been adept at promoting positive
parent–child interactions and cognitive stimulation in
the home. Such evidence-based programs provide infor-
mation, skill building and consultation for families, arm-
ing them with a range of tools to encourage their young
children’s development. Based on the results of our
study, promoting cognitive stimulation at home is also
critical to impact healthy nutrition and physical activity
practices, particularly for low income children and
children whose mothers have less than a high school
education. Building on evidence-based models, pediatri-
cians may engage families through referrals to home and
center based programs, or through practice-based inter-
ventions that may range in intensity from a reading cam-
paign such as “Reach out and Read” [25] to more
comprehensive models that use developmental special-
ists integrated in primary care.
Limitations and strengths
While prior work that examined the relationship between
cognitive stimulation and children’s BMI used the HOME
short form scale, [7] to achieve our proposes we had to
create a cognitive stimulation composite by matching
available items in the FACES parent interview to those in
the HOME. Although items in both sets did not differ sig-
nificantly (See Table 2), our measure may not have been
as sensitive at capturing the home cognitive environment
as the HOME-SF [21]. This possible resulting lack of sen-
sitivity may have contributed to the difference between
Page 6 of 7
our results and those of Strauss and Knight [7]. However,
differences in measurement may not fully account for the
lack of findings since we also studied a different popula-
tion. In addition, FACES 2006 [19] did not contain infor-
mation on healthy eating practices and we therefore had
to focus our nutrition variable on junk food consumption.
Finally, information on physical activity was limited to
parental reports based on a few broad questions on
children’s engagement in park/ recreational activities and
participation in games, sports and exercise.
Despite these limitations, our study has significant
strengths. In exploring the relationship between nutri-
tion, physical activity and cognitive stimulation, we ex-
panded our understanding of the relationship between
early cognitive stimulation, junk food consumption and
physical activity. We used a sample of low income
children with a high incidence of overweight and obesity,
which further informs the design of interventions that
target obesity promoting behaviors and practices with
high-risk populations.
Conclusion
Efforts to address and prevent early childhood obesity
need to consider interventions to help parents and care-
givers provide learning and cognitively stimulating home
environments for children. The absence of these oppor-
tunities may negatively influence children’s physical
activity and nutritional intake, and ultimately their body
size. A wide range of evidence based programs, delivered
through home visiting, center based and pediatric prac-
tices have successfully targeted the home environment
to improve child development outcomes. These pro-
grams should be extended to address young children’s
obesity risk. Future research should examine specific
parenting and child characteristics that may influence
the relationship between the home cognitive environ-
ment, nutrition and physical activity.
Abbreviations
BMI: Body Mass Index; FACES: The Family and Child Experiences Survey;
HOME-SF: The Home Observation for Measurement of the Environment
Short Form; VIP: The Video Interaction Project
Acknowledgments
None.
Funding
Dr. Duch’s work on this publication was supported by the National Center
for Advancing Translational Sciences, NIH UL1 TR000040 and by the National
Heart, Lung, Blood and Sleep Institute, NIH R25 HL105401.
Availability of data and materials
Data for FACES can be obtained here: http://www.researchconnections.org/
childcare/studies/28421.
Authors’ contributions
SOdB conducted assisted in the conceptualization of the paper, conducted
statistical analysis and wrote the first draft of the paper. HD conceptualized
Bosch and Duch BMC Pediatrics (2017) 17:178 Page 7 of 7

the paper, oversaw statistical analysis and revised the manuscript. Both 17. Sallis JF, Nader PR, Broyles SL, et al. Correlates of physical activity at home in
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